Provider Demographics
NPI:1821190224
Name:NELSON, RENEE SUSANNE (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:SUSANNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91979-1009
Mailing Address - Country:US
Mailing Address - Phone:619-508-0908
Mailing Address - Fax:619-693-3242
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2499
Practice Address - Country:US
Practice Address - Phone:808-691-7143
Practice Address - Fax:808-691-7496
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78214207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G782140Medicaid
BM836ZOtherMEDICARE PTAN
CA00G782140Medicaid
BM836ZMedicare PIN
WG78214AMedicare PIN